Post-World War II psychiatry: 70 years of momentous change

A large percentage of psychiatrists practicing today are Boomers, and have experienced the tumultuous change in their profession since the end of World War II. At a recent Grand Rounds presentation in the Department of Neurology & Psychiatry at Saint Louis University, participants examined major changes and paradigm shifts that have reshaped psychiatry since 1946. The audience, which included me, contributed historical observations to the list of those changes and shifts, which I’ve classified here for your ben­efit, whether or not you are a Boomer.

Medical advances
Consider these discoveries and developments:
   • Penicillin in 1947, which led to a reduction in cases of psychosis caused by tertiary syphilis, a disease that accounted for 10% to 15% of state hos­pital admissions.
   • Lithium in 1948, the first pharma­ceutical treatment for mania.
   • Chlorpromazine, the first anti­psychotic drug, in 1952, launching the psychopharmacology era and ending lifetime institutional sequestration as the only “treatment” for serious mental disorders.
   • Monoamine oxidase inhibitors in 1959, from observations that iproniazid, a drug used in tuberculosis sanitariums, improved the mood of tuberculosis patients. This was the first pharmaco­therapy for depression, which had been treated with electroconvulsive therapy (ECT), developed in the 1930s.
   • Tricyclic antidepressants, starting with imipramine in the late 1950s, dur­ing attempts to synthesize additional phenothiazine antipsychotics.
   • Diazepam, introduced in 1963 for its anti-anxiety effects, became the most widely used drug in the world over the next 2 decades.
   • Pre-frontal lobotomy to treat severe psychiatric disorders. The neurosurgeon-inventor of this so-called medical advance won the 1949 Nobel Prize for Medicine or Physiology. The procedure was rap­idly discredited after the development of antipsychotic drugs.
   • Fluoxetine, the first selective sero­tonin reuptake inhibitor, in 1987, revo­lutionized the treatment of depression, especially in primary care settings.
   • Clozapine, as an effective treat­ment for refractory and suicidal schizophrenia, and the spawning of second-generation antipsychotics. These newer agents shifted focus from neurologic adverse effects (extrapy­ramidal symptoms, tardive dyskinesia) to cardio-metabolic side effects (obesity, diabetes, dyslipidemia, and hypertension).
 

Changes to the landscape of health care
Three noteworthy developments made the list:
   • The Community Mental Health Act of 1963, signed into law by President John F. Kennedy, revolu­tionized psychiatric care by shifting delivery of care from inpatient, hospital-based facilities to outpatient, clinic-based centers. There are now close to 800 community mental health centers in the United States, where care is dominated by non-physician mental health providers—in contrast to the era of state hospitals, during which phy­sicians and nurses provided care for mentally ill patients.
   • Deinstitutionalization. This move-ment gathered momentum in the 1970s and 1980s, leading to clos­ing of the majority of state hospitals, with tragic consequences for the seri­ously mentally ill—including early demise, homelessness, substance abuse, and incarceration. In fact, the large percentage of mentally ill peo­ple in U.S. jails and prisons, instead of in a hospital, represents what has been labeled trans-institutionalization (see my March 2008 editorial, “Bring back the asylums?,” available at CurrentPsychiatry.com).
    • Managed care, emerging in the late 1980s and early 1990s, caused a seismic disturbance in the delivery of, and reimbursement for, psychiat­ric care. The result was a significant decline in access to, and quality of, care—especially the so-called carve-out model that reduced payment for psychiatric care even more drastically than for general medical care. Under managed care, the priority became saving money, rather than saving lives. Average hospital stay for patients who had a psychiatric disorder, which was years in the pre-pharmacotherapy era, and weeks or months after that, shrunk to a few days under managed care.

Changes in professional direction
Two major shifts in the complexion of the specialty were identified:
   • The decline of psychoanalysis, which had dominated psychiatry for decades (the 1940s through the 1970s), was a major shift in the conceptual­ization, training, and delivery of care in psychiatry. The rise of biological psychiatry and the medical model of psychiatric brain disorders, as well as the emergence of evidence-based (and briefer) psychotherapies (eg, cognitive-behavioral therapy, dialectical behav­ior therapy, and interpersonal therapy), gradually replaced the Freudian model of mental illness.

As a result, it became no longer nec­essary to be a certified psychoanalyst to be named chair of a department of psy­chiatry. The impact of this change on psychiatric training has been profound, because medical management by psy­chiatrists superseded psychotherapy— given the brief hospitalization that is required and the diminishing coverage for psychotherapy by insurers.

   • Delegation of psychosocial treatments to non-psychiatrists. The unintended consequences of psychia­trists’ change of focus to 1) consulta­tion on medical/surgical patients and 2) the medical evaluation, diagnosis, and pharmacotherapy of mental dis­orders led to the so-called “dual treat­ment model” for the most seriously mentally ill patients: The physician provides medical management and non-physician mental health profes­sionals provide counseling, psychoso­cial therapy, and rehabilitation.

Disruptive breakthroughs
Several are notable:
   • National Institute of Mental Health (NIMH). Establishment of NIMH in April 1949 was a major step toward funding research into psychiatric disorders. Billions of dollars have been invested to gen­erate knowledge about the causes, treatment, course, and prevention of mental illness. No other coun­try has spent as much on psychi­atric research. It would have been nearly impossible to discover what we know today without the work of NIMH.
   • Neuroscience. The meteoric rise of neuroscience from the 1960s to the present has had a dramatic effect, transforming old psychiatry and the study and therapy of the mind to a focus on the brain-mind continuum and the prospects of brain repair and neuroplasticity. Psychiatry is now regarded as a clin­ical neuroscience specialty of brain disorders that manifest as changes in thought, affect, mood, cognition, and behavior.
   • Brain imaging. Techniques developed since the 1970s—the veritable alphabet soup of CT, PET, SPECT, MRI, MRS, fMRI, and DTI— has revolutionized understanding of brain structure and function in all psychiatric disorders but especially in psychotic and mood disorders.
   • Molecular genetics. Advances over the past 2 decades have shed unprecedented light on the complex genetics of psychiatric disorders. It is becoming apparent that most psychiatric disorders are caused via gene-by-environment interaction; etiology is therefore a consequence of genetic and non-genetic variables. Risk genes, copy number variants, and de novo mutations are being discovered almost weekly, and progress in epigenetics holds prom­ise for preventing medical disorders, including psychiatric illness.
    • Neuromodulation. Advances represent an important paradigm shift, from pharmacotherapy to brain stimulation. Several tech­niques have been approved by the FDA, including transcranial mag­netic stimulation, vagus nerve stim­ulation, and deep brain stimulation, to supplement, and perhaps eventu­ally supplant, ECT.

Legal intrusiveness
No other medical specialty has been subject to laws governing clini­cal practice as psychiatry has been. Progressive intrusion of laws (osten­sibly, enacted to protect the civil rights of “the disabled”) ends up hurting patients who refuse admis­sion and then often harm them­selves or others or decline urgent treatment, which can be associated with loss of brain tissue in acute psychotic, manic, and depressed states. No legal shackles apply to treating unconscious stroke patients, delirious geriatric patients, or semi­conscious myocardial infarction patients when they are admitted to a hospital.

Distortions of the anti-psychiatry movement
The antipsychiatry movement pre­ceded the Baby Boomer era by a cen­tury but has continued unabated. The movement gained momentum and became more defamatory after release of the movie One Flew Over the Cuckoo’s Nest in 1975, which por­trayed psychiatry in a purely nega­tive light. Despite progress in public understanding of psychiatry, and tangible improvements in practice, the stigma of mental illness per­sists. Media portrayals, including motion pictures, continue to distort the good that psychiatrists do for their patients.

Gender and sexuality
   • Gender distribution of psy­chiatrists. A major shift occurred over the past 7 decades, reflecting the same pattern that has been docu­mented in other medical specialties. At least one-half of psychiatry resi­dents are now women—a welcome change from the pre-1946 era, when nearly all psychiatrists were men. This demographic transformation has had an impact on the dynamics of psychiatric practice.
    • Acceptance and depatholo­gization of homosexuality. Until 1974, homosexuality was considered a psychiatric disorder, and many homosexual persons sought treat­ment. That year, membership of the American Psychiatric Association voted to remove homosexual­ity from DSM-II and to no longer regard it as a behavioral abnormal­ity. This was a huge step toward de-pathologizing same-sex orienta­tion and love, and might have been the major impetus for the progres­sive social acceptance of gay, lesbian, and transgendered people over the past 4 decades.

The DSM paradigm shift in psychiatric diagnosis
   • DSM-III. Perhaps the most radi­cal change in the diagnostic criteria of psychiatric disorders occurred in 1980, with introduction of DSM-III to replace DSM-I and DSM-II, which were absurdly vague, unreliable, and with poor validity.

The move toward more opera­tional and reliable diagnostic require­ments began with the Research Diagnostic Criteria, developed by the Department of Psychiatry at Washington University in St. Louis. DSM-III represented a complete par­adigm shift in psychiatric diagnosis. Subsequent editions maintained the same methodology, with relatively modest changes. The field expects continued evolution in DSM diag­nostic criteria, including the future inclusion of biomarkers, based on sound, controlled studies.
   • Recognizing PTSD. Develop-ment of posttraumatic stress disor­der (PTSD) as a diagnostic entity, and its inclusion in DSM-III, were major changes in psychiatric nosol­ogy. At last, the old terms—shell shock, battle fatigue, neurasthe­nia—were legitimized as a recogniz­able syndrome secondary to major life trauma, including war and rape. That legitimacy has instigated sub­stantial clinical and research interest in identifying how serious psycho­pathology can be triggered by life events.

Pharmaceutical industry debacle
Few industries have fallen so far from grace in the eyes of psychiatric profes­sionals and the public as the manufac­turers of psychotropic drugs.

At the dawn of the psychophar­macology era (the 1950s, 1960s, and 1970s) pharmaceutical companies were respected and regarded by phy­sicians and patients as a vital partner in health care for their discovery and development of medications to treat psychiatric disorders. That image was tarnished in the 1990s, however, with the approval and release of several atypical antipsychotics. Cutthroat competition, questionable publication methods, concealment of negative findings, and excessive spending on marketing, including FDA-approved educational programs for clinicians on efficacy, safety, and dosing, all con­tributed to escalating cynicism about the industry. Academic faculty who received research grants to conduct FDA-required clinical trials of new agents were painted with the same brush.

Disclosure of potential conflict of interest became a mandatory proce­dure at universities and for NIMH grant applicants and journal pub­lishers. Class-action lawsuits against companies that manufacture second-generation antipsychotics—filed for lack of transparency about metabolic side effects—exacerbated the inten­sity of criticism and condemnation.

Although new drug develop­ment has become measurably more rigorous and ethical because of self-regulation, combined with vigorous government scrutiny and regulation, demonization of the pharmaceuti­cal industry remains unabated. That might be the reason why several major pharmaceutical companies have abandoned research and devel­opment of psychotropic drugs. That is likely to impede progress in psy­chopharmacotherapeutics; after all, no other private or government entity develops drugs for patients who have a psychiatric illness. The need for such agents is great: There is no FDA-indicated drug for the majority of DSM-5 diagnoses.

We entrust the future to next generations
Momentous events have transformed psychiatry during the lifespan of Baby Boomers like me and many of you. Because the cohort of 80 million Baby Boomers has comprised a significant percentage of the nation’s scientists, media representatives, members of the American Psychiatric Association, academicians, and community lead­ers over the past few decades, it is conceivable that the Baby Boomer generation helped trigger most of the transformative changes in psychiatry we have seen over the past 70 years.

I can only wonder: What direc­tion will psychiatry take in the age of Generation X, Generation Y, and the Millennials? Only this is certain: Psychiatry will continue to evolve— long after Baby Boomers are gone.

A large percentage of psychiatrists practicing today are Boomers, and have experienced the tumultuous change in their profession since the end of World War II. At a recent Grand Rounds presentation in the Department of Neurology & Psychiatry at Saint Louis University, participants examined major changes and paradigm shifts that have reshaped psychiatry since 1946. The audience, which included me, contributed historical observations to the list of those changes and shifts, which I’ve classified here for your ben­efit, whether or not you are a Boomer.

Medical advances
Consider these discoveries and developments:
   • Penicillin in 1947, which led to a reduction in cases of psychosis caused by tertiary syphilis, a disease that accounted for 10% to 15% of state hos­pital admissions.
   • Lithium in 1948, the first pharma­ceutical treatment for mania.
   • Chlorpromazine, the first anti­psychotic drug, in 1952, launching the psychopharmacology era and ending lifetime institutional sequestration as the only “treatment” for serious mental disorders.
   • Monoamine oxidase inhibitors in 1959, from observations that iproniazid, a drug used in tuberculosis sanitariums, improved the mood of tuberculosis patients. This was the first pharmaco­therapy for depression, which had been treated with electroconvulsive therapy (ECT), developed in the 1930s.
   • Tricyclic antidepressants, starting with imipramine in the late 1950s, dur­ing attempts to synthesize additional phenothiazine antipsychotics.
   • Diazepam, introduced in 1963 for its anti-anxiety effects, became the most widely used drug in the world over the next 2 decades.
   • Pre-frontal lobotomy to treat severe psychiatric disorders. The neurosurgeon-inventor of this so-called medical advance won the 1949 Nobel Prize for Medicine or Physiology. The procedure was rap­idly discredited after the development of antipsychotic drugs.
   • Fluoxetine, the first selective sero­tonin reuptake inhibitor, in 1987, revo­lutionized the treatment of depression, especially in primary care settings.
   • Clozapine, as an effective treat­ment for refractory and suicidal schizophrenia, and the spawning of second-generation antipsychotics. These newer agents shifted focus from neurologic adverse effects (extrapy­ramidal symptoms, tardive dyskinesia) to cardio-metabolic side effects (obesity, diabetes, dyslipidemia, and hypertension).
 

Changes to the landscape of health care
Three noteworthy developments made the list:
   • The Community Mental Health Act of 1963, signed into law by President John F. Kennedy, revolu­tionized psychiatric care by shifting delivery of care from inpatient, hospital-based facilities to outpatient, clinic-based centers. There are now close to 800 community mental health centers in the United States, where care is dominated by non-physician mental health providers—in contrast to the era of state hospitals, during which phy­sicians and nurses provided care for mentally ill patients.
   • Deinstitutionalization. This move-ment gathered momentum in the 1970s and 1980s, leading to clos­ing of the majority of state hospitals, with tragic consequences for the seri­ously mentally ill—including early demise, homelessness, substance abuse, and incarceration. In fact, the large percentage of mentally ill peo­ple in U.S. jails and prisons, instead of in a hospital, represents what has been labeled trans-institutionalization (see my March 2008 editorial, “Bring back the asylums?,” available at CurrentPsychiatry.com).
    • Managed care, emerging in the late 1980s and early 1990s, caused a seismic disturbance in the delivery of, and reimbursement for, psychiat­ric care. The result was a significant decline in access to, and quality of, care—especially the so-called carve-out model that reduced payment for psychiatric care even more drastically than for general medical care. Under managed care, the priority became saving money, rather than saving lives. Average hospital stay for patients who had a psychiatric disorder, which was years in the pre-pharmacotherapy era, and weeks or months after that, shrunk to a few days under managed care.

Changes in professional direction
Two major shifts in the complexion of the specialty were identified:
   • The decline of psychoanalysis, which had dominated psychiatry for decades (the 1940s through the 1970s), was a major shift in the conceptual­ization, training, and delivery of care in psychiatry. The rise of biological psychiatry and the medical model of psychiatric brain disorders, as well as the emergence of evidence-based (and briefer) psychotherapies (eg, cognitive-behavioral therapy, dialectical behav­ior therapy, and interpersonal therapy), gradually replaced the Freudian model of mental illness.

As a result, it became no longer nec­essary to be a certified psychoanalyst to be named chair of a department of psy­chiatry. The impact of this change on psychiatric training has been profound, because medical management by psy­chiatrists superseded psychotherapy— given the brief hospitalization that is required and the diminishing coverage for psychotherapy by insurers.

   • Delegation of psychosocial treatments to non-psychiatrists. The unintended consequences of psychia­trists’ change of focus to 1) consulta­tion on medical/surgical patients and 2) the medical evaluation, diagnosis, and pharmacotherapy of mental dis­orders led to the so-called “dual treat­ment model” for the most seriously mentally ill patients: The physician provides medical management and non-physician mental health profes­sionals provide counseling, psychoso­cial therapy, and rehabilitation.

Disruptive breakthroughs
Several are notable:
   • National Institute of Mental Health (NIMH). Establishment of NIMH in April 1949 was a major step toward funding research into psychiatric disorders. Billions of dollars have been invested to gen­erate knowledge about the causes, treatment, course, and prevention of mental illness. No other coun­try has spent as much on psychi­atric research. It would have been nearly impossible to discover what we know today without the work of NIMH.
   • Neuroscience. The meteoric rise of neuroscience from the 1960s to the present has had a dramatic effect, transforming old psychiatry and the study and therapy of the mind to a focus on the brain-mind continuum and the prospects of brain repair and neuroplasticity. Psychiatry is now regarded as a clin­ical neuroscience specialty of brain disorders that manifest as changes in thought, affect, mood, cognition, and behavior.
   • Brain imaging. Techniques developed since the 1970s—the veritable alphabet soup of CT, PET, SPECT, MRI, MRS, fMRI, and DTI— has revolutionized understanding of brain structure and function in all psychiatric disorders but especially in psychotic and mood disorders.
   • Molecular genetics. Advances over the past 2 decades have shed unprecedented light on the complex genetics of psychiatric disorders. It is becoming apparent that most psychiatric disorders are caused via gene-by-environment interaction; etiology is therefore a consequence of genetic and non-genetic variables. Risk genes, copy number variants, and de novo mutations are being discovered almost weekly, and progress in epigenetics holds prom­ise for preventing medical disorders, including psychiatric illness.
    • Neuromodulation. Advances represent an important paradigm shift, from pharmacotherapy to brain stimulation. Several tech­niques have been approved by the FDA, including transcranial mag­netic stimulation, vagus nerve stim­ulation, and deep brain stimulation, to supplement, and perhaps eventu­ally supplant, ECT.

Legal intrusiveness
No other medical specialty has been subject to laws governing clini­cal practice as psychiatry has been. Progressive intrusion of laws (osten­sibly, enacted to protect the civil rights of “the disabled”) ends up hurting patients who refuse admis­sion and then often harm them­selves or others or decline urgent treatment, which can be associated with loss of brain tissue in acute psychotic, manic, and depressed states. No legal shackles apply to treating unconscious stroke patients, delirious geriatric patients, or semi­conscious myocardial infarction patients when they are admitted to a hospital.

Distortions of the anti-psychiatry movement
The antipsychiatry movement pre­ceded the Baby Boomer era by a cen­tury but has continued unabated. The movement gained momentum and became more defamatory after release of the movie One Flew Over the Cuckoo’s Nest in 1975, which por­trayed psychiatry in a purely nega­tive light. Despite progress in public understanding of psychiatry, and tangible improvements in practice, the stigma of mental illness per­sists. Media portrayals, including motion pictures, continue to distort the good that psychiatrists do for their patients.

Gender and sexuality
   • Gender distribution of psy­chiatrists. A major shift occurred over the past 7 decades, reflecting the same pattern that has been docu­mented in other medical specialties. At least one-half of psychiatry resi­dents are now women—a welcome change from the pre-1946 era, when nearly all psychiatrists were men. This demographic transformation has had an impact on the dynamics of psychiatric practice.
    • Acceptance and depatholo­gization of homosexuality. Until 1974, homosexuality was considered a psychiatric disorder, and many homosexual persons sought treat­ment. That year, membership of the American Psychiatric Association voted to remove homosexual­ity from DSM-II and to no longer regard it as a behavioral abnormal­ity. This was a huge step toward de-pathologizing same-sex orienta­tion and love, and might have been the major impetus for the progres­sive social acceptance of gay, lesbian, and transgendered people over the past 4 decades.

The DSM paradigm shift in psychiatric diagnosis
   • DSM-III. Perhaps the most radi­cal change in the diagnostic criteria of psychiatric disorders occurred in 1980, with introduction of DSM-III to replace DSM-I and DSM-II, which were absurdly vague, unreliable, and with poor validity.

The move toward more opera­tional and reliable diagnostic require­ments began with the Research Diagnostic Criteria, developed by the Department of Psychiatry at Washington University in St. Louis. DSM-III represented a complete par­adigm shift in psychiatric diagnosis. Subsequent editions maintained the same methodology, with relatively modest changes. The field expects continued evolution in DSM diag­nostic criteria, including the future inclusion of biomarkers, based on sound, controlled studies.
   • Recognizing PTSD. Develop-ment of posttraumatic stress disor­der (PTSD) as a diagnostic entity, and its inclusion in DSM-III, were major changes in psychiatric nosol­ogy. At last, the old terms—shell shock, battle fatigue, neurasthe­nia—were legitimized as a recogniz­able syndrome secondary to major life trauma, including war and rape. That legitimacy has instigated sub­stantial clinical and research interest in identifying how serious psycho­pathology can be triggered by life events.

Pharmaceutical industry debacle
Few industries have fallen so far from grace in the eyes of psychiatric profes­sionals and the public as the manufac­turers of psychotropic drugs.

At the dawn of the psychophar­macology era (the 1950s, 1960s, and 1970s) pharmaceutical companies were respected and regarded by phy­sicians and patients as a vital partner in health care for their discovery and development of medications to treat psychiatric disorders. That image was tarnished in the 1990s, however, with the approval and release of several atypical antipsychotics. Cutthroat competition, questionable publication methods, concealment of negative findings, and excessive spending on marketing, including FDA-approved educational programs for clinicians on efficacy, safety, and dosing, all con­tributed to escalating cynicism about the industry. Academic faculty who received research grants to conduct FDA-required clinical trials of new agents were painted with the same brush.

Disclosure of potential conflict of interest became a mandatory proce­dure at universities and for NIMH grant applicants and journal pub­lishers. Class-action lawsuits against companies that manufacture second-generation antipsychotics—filed for lack of transparency about metabolic side effects—exacerbated the inten­sity of criticism and condemnation.

Although new drug develop­ment has become measurably more rigorous and ethical because of self-regulation, combined with vigorous government scrutiny and regulation, demonization of the pharmaceuti­cal industry remains unabated. That might be the reason why several major pharmaceutical companies have abandoned research and devel­opment of psychotropic drugs. That is likely to impede progress in psy­chopharmacotherapeutics; after all, no other private or government entity develops drugs for patients who have a psychiatric illness. The need for such agents is great: There is no FDA-indicated drug for the majority of DSM-5 diagnoses.

We entrust the future to next generations
Momentous events have transformed psychiatry during the lifespan of Baby Boomers like me and many of you. Because the cohort of 80 million Baby Boomers has comprised a significant percentage of the nation’s scientists, media representatives, members of the American Psychiatric Association, academicians, and community lead­ers over the past few decades, it is conceivable that the Baby Boomer generation helped trigger most of the transformative changes in psychiatry we have seen over the past 70 years.

I can only wonder: What direc­tion will psychiatry take in the age of Generation X, Generation Y, and the Millennials? Only this is certain: Psychiatry will continue to evolve— long after Baby Boomers are gone.

A large percentage of psychiatrists practicing today are Boomers, and have experienced the tumultuous change in their profession since the end of World War II. At a recent Grand Rounds presentation in the Department of Neurology & Psychiatry at Saint Louis University, participants examined major changes and paradigm shifts that have reshaped psychiatry since 1946. The audience, which included me, contributed historical observations to the list of those changes and shifts, which I’ve classified here for your ben­efit, whether or not you are a Boomer.

Medical advances
Consider these discoveries and developments:
   • Penicillin in 1947, which led to a reduction in cases of psychosis caused by tertiary syphilis, a disease that accounted for 10% to 15% of state hos­pital admissions.
   • Lithium in 1948, the first pharma­ceutical treatment for mania.
   • Chlorpromazine, the first anti­psychotic drug, in 1952, launching the psychopharmacology era and ending lifetime institutional sequestration as the only “treatment” for serious mental disorders.
   • Monoamine oxidase inhibitors in 1959, from observations that iproniazid, a drug used in tuberculosis sanitariums, improved the mood of tuberculosis patients. This was the first pharmaco­therapy for depression, which had been treated with electroconvulsive therapy (ECT), developed in the 1930s.
   • Tricyclic antidepressants, starting with imipramine in the late 1950s, dur­ing attempts to synthesize additional phenothiazine antipsychotics.
   • Diazepam, introduced in 1963 for its anti-anxiety effects, became the most widely used drug in the world over the next 2 decades.
   • Pre-frontal lobotomy to treat severe psychiatric disorders. The neurosurgeon-inventor of this so-called medical advance won the 1949 Nobel Prize for Medicine or Physiology. The procedure was rap­idly discredited after the development of antipsychotic drugs.
   • Fluoxetine, the first selective sero­tonin reuptake inhibitor, in 1987, revo­lutionized the treatment of depression, especially in primary care settings.
   • Clozapine, as an effective treat­ment for refractory and suicidal schizophrenia, and the spawning of second-generation antipsychotics. These newer agents shifted focus from neurologic adverse effects (extrapy­ramidal symptoms, tardive dyskinesia) to cardio-metabolic side effects (obesity, diabetes, dyslipidemia, and hypertension).
 

Changes to the landscape of health care
Three noteworthy developments made the list:
   • The Community Mental Health Act of 1963, signed into law by President John F. Kennedy, revolu­tionized psychiatric care by shifting delivery of care from inpatient, hospital-based facilities to outpatient, clinic-based centers. There are now close to 800 community mental health centers in the United States, where care is dominated by non-physician mental health providers—in contrast to the era of state hospitals, during which phy­sicians and nurses provided care for mentally ill patients.
   • Deinstitutionalization. This move-ment gathered momentum in the 1970s and 1980s, leading to clos­ing of the majority of state hospitals, with tragic consequences for the seri­ously mentally ill—including early demise, homelessness, substance abuse, and incarceration. In fact, the large percentage of mentally ill peo­ple in U.S. jails and prisons, instead of in a hospital, represents what has been labeled trans-institutionalization (see my March 2008 editorial, “Bring back the asylums?,” available at CurrentPsychiatry.com).
    • Managed care, emerging in the late 1980s and early 1990s, caused a seismic disturbance in the delivery of, and reimbursement for, psychiat­ric care. The result was a significant decline in access to, and quality of, care—especially the so-called carve-out model that reduced payment for psychiatric care even more drastically than for general medical care. Under managed care, the priority became saving money, rather than saving lives. Average hospital stay for patients who had a psychiatric disorder, which was years in the pre-pharmacotherapy era, and weeks or months after that, shrunk to a few days under managed care.

Changes in professional direction
Two major shifts in the complexion of the specialty were identified:
   • The decline of psychoanalysis, which had dominated psychiatry for decades (the 1940s through the 1970s), was a major shift in the conceptual­ization, training, and delivery of care in psychiatry. The rise of biological psychiatry and the medical model of psychiatric brain disorders, as well as the emergence of evidence-based (and briefer) psychotherapies (eg, cognitive-behavioral therapy, dialectical behav­ior therapy, and interpersonal therapy), gradually replaced the Freudian model of mental illness.

As a result, it became no longer nec­essary to be a certified psychoanalyst to be named chair of a department of psy­chiatry. The impact of this change on psychiatric training has been profound, because medical management by psy­chiatrists superseded psychotherapy— given the brief hospitalization that is required and the diminishing coverage for psychotherapy by insurers.

   • Delegation of psychosocial treatments to non-psychiatrists. The unintended consequences of psychia­trists’ change of focus to 1) consulta­tion on medical/surgical patients and 2) the medical evaluation, diagnosis, and pharmacotherapy of mental dis­orders led to the so-called “dual treat­ment model” for the most seriously mentally ill patients: The physician provides medical management and non-physician mental health profes­sionals provide counseling, psychoso­cial therapy, and rehabilitation.

Disruptive breakthroughs
Several are notable:
   • National Institute of Mental Health (NIMH). Establishment of NIMH in April 1949 was a major step toward funding research into psychiatric disorders. Billions of dollars have been invested to gen­erate knowledge about the causes, treatment, course, and prevention of mental illness. No other coun­try has spent as much on psychi­atric research. It would have been nearly impossible to discover what we know today without the work of NIMH.
   • Neuroscience. The meteoric rise of neuroscience from the 1960s to the present has had a dramatic effect, transforming old psychiatry and the study and therapy of the mind to a focus on the brain-mind continuum and the prospects of brain repair and neuroplasticity. Psychiatry is now regarded as a clin­ical neuroscience specialty of brain disorders that manifest as changes in thought, affect, mood, cognition, and behavior.
   • Brain imaging. Techniques developed since the 1970s—the veritable alphabet soup of CT, PET, SPECT, MRI, MRS, fMRI, and DTI— has revolutionized understanding of brain structure and function in all psychiatric disorders but especially in psychotic and mood disorders.
   • Molecular genetics. Advances over the past 2 decades have shed unprecedented light on the complex genetics of psychiatric disorders. It is becoming apparent that most psychiatric disorders are caused via gene-by-environment interaction; etiology is therefore a consequence of genetic and non-genetic variables. Risk genes, copy number variants, and de novo mutations are being discovered almost weekly, and progress in epigenetics holds prom­ise for preventing medical disorders, including psychiatric illness.
    • Neuromodulation. Advances represent an important paradigm shift, from pharmacotherapy to brain stimulation. Several tech­niques have been approved by the FDA, including transcranial mag­netic stimulation, vagus nerve stim­ulation, and deep brain stimulation, to supplement, and perhaps eventu­ally supplant, ECT.

Legal intrusiveness
No other medical specialty has been subject to laws governing clini­cal practice as psychiatry has been. Progressive intrusion of laws (osten­sibly, enacted to protect the civil rights of “the disabled”) ends up hurting patients who refuse admis­sion and then often harm them­selves or others or decline urgent treatment, which can be associated with loss of brain tissue in acute psychotic, manic, and depressed states. No legal shackles apply to treating unconscious stroke patients, delirious geriatric patients, or semi­conscious myocardial infarction patients when they are admitted to a hospital.

Distortions of the anti-psychiatry movement
The antipsychiatry movement pre­ceded the Baby Boomer era by a cen­tury but has continued unabated. The movement gained momentum and became more defamatory after release of the movie One Flew Over the Cuckoo’s Nest in 1975, which por­trayed psychiatry in a purely nega­tive light. Despite progress in public understanding of psychiatry, and tangible improvements in practice, the stigma of mental illness per­sists. Media portrayals, including motion pictures, continue to distort the good that psychiatrists do for their patients.

Gender and sexuality
   • Gender distribution of psy­chiatrists. A major shift occurred over the past 7 decades, reflecting the same pattern that has been docu­mented in other medical specialties. At least one-half of psychiatry resi­dents are now women—a welcome change from the pre-1946 era, when nearly all psychiatrists were men. This demographic transformation has had an impact on the dynamics of psychiatric practice.
    • Acceptance and depatholo­gization of homosexuality. Until 1974, homosexuality was considered a psychiatric disorder, and many homosexual persons sought treat­ment. That year, membership of the American Psychiatric Association voted to remove homosexual­ity from DSM-II and to no longer regard it as a behavioral abnormal­ity. This was a huge step toward de-pathologizing same-sex orienta­tion and love, and might have been the major impetus for the progres­sive social acceptance of gay, lesbian, and transgendered people over the past 4 decades.

The DSM paradigm shift in psychiatric diagnosis
   • DSM-III. Perhaps the most radi­cal change in the diagnostic criteria of psychiatric disorders occurred in 1980, with introduction of DSM-III to replace DSM-I and DSM-II, which were absurdly vague, unreliable, and with poor validity.

The move toward more opera­tional and reliable diagnostic require­ments began with the Research Diagnostic Criteria, developed by the Department of Psychiatry at Washington University in St. Louis. DSM-III represented a complete par­adigm shift in psychiatric diagnosis. Subsequent editions maintained the same methodology, with relatively modest changes. The field expects continued evolution in DSM diag­nostic criteria, including the future inclusion of biomarkers, based on sound, controlled studies.
   • Recognizing PTSD. Develop-ment of posttraumatic stress disor­der (PTSD) as a diagnostic entity, and its inclusion in DSM-III, were major changes in psychiatric nosol­ogy. At last, the old terms—shell shock, battle fatigue, neurasthe­nia—were legitimized as a recogniz­able syndrome secondary to major life trauma, including war and rape. That legitimacy has instigated sub­stantial clinical and research interest in identifying how serious psycho­pathology can be triggered by life events.

Pharmaceutical industry debacle
Few industries have fallen so far from grace in the eyes of psychiatric profes­sionals and the public as the manufac­turers of psychotropic drugs.

At the dawn of the psychophar­macology era (the 1950s, 1960s, and 1970s) pharmaceutical companies were respected and regarded by phy­sicians and patients as a vital partner in health care for their discovery and development of medications to treat psychiatric disorders. That image was tarnished in the 1990s, however, with the approval and release of several atypical antipsychotics. Cutthroat competition, questionable publication methods, concealment of negative findings, and excessive spending on marketing, including FDA-approved educational programs for clinicians on efficacy, safety, and dosing, all con­tributed to escalating cynicism about the industry. Academic faculty who received research grants to conduct FDA-required clinical trials of new agents were painted with the same brush.

Disclosure of potential conflict of interest became a mandatory proce­dure at universities and for NIMH grant applicants and journal pub­lishers. Class-action lawsuits against companies that manufacture second-generation antipsychotics—filed for lack of transparency about metabolic side effects—exacerbated the inten­sity of criticism and condemnation.

Although new drug develop­ment has become measurably more rigorous and ethical because of self-regulation, combined with vigorous government scrutiny and regulation, demonization of the pharmaceuti­cal industry remains unabated. That might be the reason why several major pharmaceutical companies have abandoned research and devel­opment of psychotropic drugs. That is likely to impede progress in psy­chopharmacotherapeutics; after all, no other private or government entity develops drugs for patients who have a psychiatric illness. The need for such agents is great: There is no FDA-indicated drug for the majority of DSM-5 diagnoses.

We entrust the future to next generations
Momentous events have transformed psychiatry during the lifespan of Baby Boomers like me and many of you. Because the cohort of 80 million Baby Boomers has comprised a significant percentage of the nation’s scientists, media representatives, members of the American Psychiatric Association, academicians, and community lead­ers over the past few decades, it is conceivable that the Baby Boomer generation helped trigger most of the transformative changes in psychiatry we have seen over the past 70 years.

I can only wonder: What direc­tion will psychiatry take in the age of Generation X, Generation Y, and the Millennials? Only this is certain: Psychiatry will continue to evolve— long after Baby Boomers are gone.